At first sight, confidence in the COVID-19 vaccine appears high. After all, more than 635 million people worldwide have been vaccinated since public programmes started in December 2020. Vaccinations could be even faster if supplies keep up with the strong demand for 14 billion doses before the end of 2021. Even an Imperial College/YouGov survey in February 2021 shows that people worldwide are more and more willing to be vaccinated. These facts suggest that fears of vaccine hesitancy could be misplaced.

Unfortunately, the reality is not as rosy. Even before COVID-19, the World Health Organization (WHO) already labelled vaccine hesitancy as one of the top ten threats to global health, and added the term “infodemic” during the COVID-19 pandemic. Vaccine confidence also depends on many structural and non-scientific factors that often undermine it.

Only a few months into the first vaccine rollouts around the world, these are key lessons gleaned so far:

First, vaccine confidence is not uniform across the world. There are pockets of hesitation, such as France (which convened a 35-member “citizens’ vaccine panel” to build trust), Japan (which has only vaccinated a paltry 0.7 percent of its population as of 2 April, versus 60.7 percent in Israel and 30.4 percent in the United States), and the Philippines (where social media rumors after the 2016 dengue vaccine controversy turbo-charged vaccine hesitancy). If not adequately addressed, reluctance to get inoculated could deepen in these countries or even spread more broadly.

Second, trust and confidence are fragile commodities, even in the best of times. Vaccination programmes for COVID-19 are rolling out in an environment where individuals and communities are susceptible to misinformation, prone to overreact to news, and easily scared. Confidence could evaporate overnight simply due to:

• the spread of misleading or hysterical reports of adverse events such as the death of a person after receiving a shot,
• pharma companies communicating their data poorly, as happened when AstraZeneca provided US regulatory authorities out-of-date information on clinical trials, causing unnecessary confusion;
• regulators raising concerns or suspending vaccinations for safety reasons, as occurred when a January 2021 report of the deaths of 23 frail elderly people in Norway after they received the Pfizer vaccine triggered sensationalist headlines around the world, leading the WHO to assert that the “benefit-risk balance [for getting vaccinated] remains favorable in the elderly”;
• the emergence of a new COVID-19 variant that could be resistant to the existing highly effective vaccines, causing countries to adopt a needlessly cautious stance; or
• malicious state or non-state actors stirring vaccine hesitancy in a particular country such as the United Kingdom, where GCHQ, its intelligence and security information-gathering agency, has launched cyber-operations to counter anti-vaccine propaganda

Third, vaccines have now been politicised. Citizens, therefore, may not trust any rhetoric around the public health and scientific value of vaccines. Trust has been eroded at two levels. Governments worldwide already suffered from a trust deficit; the pandemic has only widened that gap. They may oversell the benefits of COVID-19 vaccines to encourage vaccinations, or over-promise “carrots” such as the resumption of travel, which authorities in Hong Kong, Malaysia, Thailand, and the United States have been dangling as incentives. If citizens do not trust their governments, feel coerced into taking vaccines, or do not see tangible benefits of getting inoculated, already tentative faith in vaccines could be weakened.

Internationally, vaccines have become a foreign policy tool. Some countries are receiving vaccines from China, Russia, and the US through preferential commercial access, outright donations or strings-attached arrangements (“vaccine diplomacy”). These countries may struggle to convince their citizens that the vaccines they get are the best available and were obtained freely, instead of second-best options accepted under duress or in desperation. Complicating the political economy of vaccines further is the unfair global intellectual property regime that has led many people to distrust the products of “greedy” highly profitable pharmaceutical companies.

Fourth, confidence could be low because people perceive that governments or companies cut corners to develop, approve, and manufacture COVID-19 vaccines so quickly. Public health officials and the media may not have offered explanations for how science, economics, and politics enabled such speed without compromising quality or safety. The are many logical reasons behind the success: Because Covid-19 affected rich countries (unlike other infectious diseases such as malaria or tuberculosis (which mainly affect poor countries), much more money and political will were channelled into its research. Also, there are more capable scientists than ever before, boosting the global capacity for knowledge exchange (including sharing of viral genetic material) and collaboration built on decades of extensive research into coronaviruses and mRNA vaccines. The basic science research into coronaviruses and vaccines already took place precisely in preparation for a pandemic such as COVID-19.

It was also much easier to enlist volunteers for vaccine testing. Pfizer, Moderna, and Johnson & Johnson recruited a total of 117,000 subjects over six months for three separate global trials. Compare that with the three trials for the one Ebola vaccine that involved only 12,000 subjects from 2015 to 2017. Fierce competition among pharmaceutical companies delivered several safe and effective vaccines in a short time.

Finally, governments guaranteed purchases of COVID-19 vaccines through a tool called advanced market commitments, which gave the pharmaceutical companies the confidence to invest more money into research and manufacturing capacity. The speed should be regarded more as an indication of the robustness of a global collaborative scientific process and the presence of adequate incentives and political will.

There are other systemic reasons for vaccine hesitancy:

• Vaccines are victims of their own success. Because people do not see smallpox, polio, and measles today, they forget that vaccines prevented all those diseases. Populations, therefore, are less cognizant of the value of vaccines because they are not as aware as before of the role they played in mitigating, indeed eliminating, the risk of death and long-term effects from certain diseases.
• People in countries that were successful in fighting COVID-19 (such as Thailand and Vietnam) or have highly trusted and accessible medical services (such as Japan and South Korea) may have become too confident in their healthcare systems, prompting them to decline getting vaccinated. Citizens spared the brunt of the pandemic may believe that their hospitals will save them if they ever get infected.
• Declining science-literacy levels may have led to poor understanding of vaccines and the science behind them. Consider how the average PISA scores for science subjects in Organisation for Economic Co-operation and Development (OECD) countries declined between 2012–2018, regressing to 2006 levels. As a practical matter, people without scientific literacy may not understand the basic risk-benefit assessments of getting inoculated.
• The effects of vaccines are invisible, leaving people unable to appreciate their value. Vaccines prevent diseases, instead of dramatically reducing pain or killing cancers. If they succeed, while the number of infections may go down eventually, at first there may be no clear sign of their effectiveness. Some may interpret this as the failure of vaccines, and therefore decline to get vaccinated.

Pragmatic, holistic, and sustainable

Given this wide range of powerful tectonic forces that may drive vaccine hesitancy, governments must significantly enhance their efforts to bolster vaccine confidence. To do this, governments must deploy political will and skill alongside science and facts.

There are three overarching strategies to achieve confidence in vaccination programs. First, governments must adopt a suite of solutions as there is no single remedy to hesitancy. Second, governments must take an all-of-society approach because they do not possess all the required skills, capacity, and trusting relationships to increase people’s willingness to get their shots. Third, these efforts must be continuous over a long term because vaccine confidence is a moving goalpost, with ever-changing circumstances and levels of trust. In short, vaccine confidence efforts must be pragmatic, holistic, and sustainable.

Understanding the vaccine-confidence continuum is crucial for developing a full suite of solutions to hesitancy. Those actively demanding COVID-19 vaccines stand at one end, while those actively hostile to them are at the other. People can be divided into three groups along that spectrum, each requiring different approaches:

• Those who understand and accept vaccines – This group needs continual health education, encouragement and perhaps policies to allow them to become “vaccine ambassadors”.
• Those who are genuinely hesitant and want more information – This group needs more non-judgmental and targeted health education to address their specific questions and doubts.
• Those who are anti-vaccine, anti-science, or impossible to convince – Although a minority, this group is highly vocal. The Centre for Countering Digital Hate recently calculated that 65 percent of anti-vaccine content on Facebook and Twitter originates from only 12 people. If education and persuasion fail, countries may need to impose penalties (such as social media bans, fines or prison sentences) on certain types of anti-vaxxer activities as they may be direct threats to public health.

This neat landscape is complicated by numerous factors contributing to vaccine hesitancy that vary across countries, age groups, education and income levels, and political and religious beliefs. Education to strengthen vaccine confidence must, therefore, be nuanced and targeted to specific types of doubters, while focusing on four main areas:

• the science behind vaccines and how they work;
• the process of selecting, approving and procuring the vaccines;
• vaccine safety and efficacy compared to the risks of COVID-19; and
• the coincidence of adverse events with “background rates of diseases” (for example, a heart attack after immunisation may be entirely due to natural causes and not to a vaccine)

When delivering vaccine education, governments must operate on several organising principles. First, information must be extremely easy to understand and delivered repeatedly. Second, the messenger is as important as the message, which is why trusted figures such as teachers or religious leaders are helpful. Three, governments must treat their citizens as adults with dignity and agency, instead of being judgmental or paternalistic.

But education alone is not enough, no matter how nuanced, targeted, or sustainable. Governments must deploy solutions to the other issues described earlier, including the following any or all of these strategies:

• ensuring the transparency of all vaccine data and partnering with communications experts to deliver press statements and describe clinical trial results in layman’s terms;
• establishing media standards for accurate vaccine reporting (such as the guidelines set by the International Federation of Journalists), with reasonable penalties for non-compliance;
• dealing with adverse events in thoughtful and compassionate ways, including the management of vaccine liability and compensation schemes that are necessary but could send the wrong signals;
• enlisting trusted or admired public figures (including famous athletes, popular entertainers, religious leaders and social-media influencers) as role models; and
• appropriately using behavioral psychology and economics to persuade citizens to get vaccinated.

Governments must realise that they do not possess all the requisite skills, capacity or trusting relationships to deliver the necessary suite of solutions. Their second overarching strategy must therefore be to pursue multisectoral and multistakeholder approaches at the domestic and international levels. At home, governments must rebuild trust with community leaders, which would then allow them to cooperate effectively and meaningfully with civil society organisations.

Lagos state in Nigeria, the efforts of migrant worker leaders in Malaysia, and the activities of African-American clergy and religious groups in the US are good examples of successful community engagement. Key figures are trained and empowered to preach the benefits of the vaccines to their constituents, their messages more powerful than anything that faceless bureaucrats or harried doctors could possibly deliver. But care must be taken not to misuse or abuse the trust that community leaders enjoy with the public.

Although vaccine confidence is usually an individual matter, with levels varying within local communities and even within the same household, there are two important international considerations that require collaboration in the global commons:

• COVID-19 vaccines are still mostly made by global companies (not regional or local ones). These businesses have a responsibility to conduct clinical trials in ethical ways and then to publish their results in peer-reviewed journals. Global pharmaceutical companies have a moral responsibility to communicate ethically and clearly, and not to profit from their public-education initiatives. Data transparency will build confidence, and information about vaccines is as much a global public good as the vaccines themselves.
• Social media platforms have an equally important responsibility. Facebook, Twitter, and Instagram have already changed their algorithms and banned some posts, users, and groups, but more can be done. There is a delicate balance between free expression and threats to public health, but this can be maintained with stronger partnerships and smart regulations worked out between social media platforms and national governments.

The third and final overarching strategy to combat vaccine hesitancy is straightforward: confidence building efforts must be sustainable and pursued over the long term. COVID-19 vaccination programs will be around for a while. Governments may never be able to declare “mission accomplished”. This means that efforts to shore up vaccine confidence must be permanent.

Indeed, if confidence building measures are done well for the COVID-19 vaccines, there will be positive spillovers for other vaccines, increased health and science literacy, and greater trust in governments.

Vaccine confidence is not the only challenge

Vaccine hesitancy is only one reason why people do not get vaccinated. Other important causes include the lack of access (logistical or financial), fear of authorities, the collective action of selfish persons waiting for herd immunity, and conscientious objections or protests against governments and societies because of perceptions of coercion or threat. These complex issues need separate solutions.

Vaccine confidence is achievable. Building it requires coalitions of the willing, led by governments that deploys political will and skill alongside science and facts. Pragmatic, holistic and sustainable solutions are crucial if nations are to build back better, fairer and healthier after the pandemic.

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This article was first published by AsiaGlobal Online. It is republished here under a Creative Commons BY-NC-ND 4.0 license. Read the original article.